Am I Really Some Crazy Guy Who Doesn't Believe in Strong Quads?

Okay, the book is out, so it's time to get back to the regular business of the blog ...

One thing I realized recently: someone not familiar with the story of my recovery might stumble upon bits of my writing, specifically my dismissal of quadriceps strengthening to heal bad knees, and say, "Well, this idiot clearly doesn't know anything."

EVERYBODY says that to cure patellofemoral pain syndrome (a.k.a. runner's knee, chondromalacia patella), you have to focus on strengthening the quads, or those large muscles in the front of your thigh. By everybody, I mean doctors, physical therapists, your grandma from Dubuque ...

And I think this advice is wrong -- sometimes dangerously so, as when following it leads you to injure yourself even further.

So does this mean I don't think quad strength matters? Strong quads, weak quads ... whatever.

Not at all.

Having strong quads is GREAT. They do help preserve your knees. My quads are quite strong right now. I spent the summer chasing aerobically fit, young (mostly) cyclists along flats and up hills in western Long Island. Some Saturdays I was in the saddle for almost 70 miles. The rides were intense. We would start with 40 to 50 cyclists. At the finish, there might be five or six of us.

But my own recovery taught me that, when your knees hurt, it's absolutely wrong to FOCUS on strengthening your quads first. Ironically, this conclusion turns out to be simple common sense and "strengthen your quads to beat knee pain" turns out to be baffling advice -- when you stop to really think about it.

Because: Your focus should be on what hurts, on the weak link in the chain. When you have bad knees and walk half a mile, or climb two flights of steps, and then have pain -- it's not your quads that are grumbling, but your knee joints. Your quads may be weak, average, or even strong (I happened to have fairly strong quads at the time I developed chronic knee pain). But one thing is certain: your knees are weak.

So you gotta strengthen your knees first. And what I discovered works best for that, as I outline in my book, is a program that focuses on easy motion that over time increases in intensity and duration. And by "over time," I mean months, not days. I fashioned a plan to heal that centered on walking and pretty much walked my way to stronger, healthier knees. THEN I got back on my bike and really started building up my quads.

I know I've blogged on this subject before. But it's so important I wanted to hit it fresh, with a new year upon us. That quad-strengthening approach is hardly ever questioned ... which is what I find truly crazy, because it really doesn't make sense. The cart has been put before the horse. Why don't physical therapists see this?

Well, one does. I'm going to cite Doug Kelsey again. If you put the two of us in a room, we might not agree on absolutely everything about healing knees (he once advocated taking glucosamine; my research led me to believe it's probably worthless), but Doug is the smartest PT, by a long shot, that I've come across anywhere.

Here he answers a reader's question about a program to heal patellofemoral pain syndrome (abbreviated below as PFS). The bold is mine:

Almost every exercise program that you find for PFS targets muscle (quadriceps strengthening, stretching of the hamstrings, etc.) and having stronger muscles is helpful but weak muscles are not the primary problem. The muscular weakness is in response to the changes in the joint. Some clinicians argue that cartilage does not respond to exercise; that it is biologically inert. However, there is ample scientific evidence proving that cartilage does respond like other biologic tissues of the body (muscle, tendon, ligament, bone) as long as the motion-force combination is within a certain range.

So you need to strengthen the joints. And you can. I'm living proof.

P.S. I'm going to start a new (occasional) feature where I lift some of the cases from the comments section and devote posts to them. One thing I know (from my own experience): people with hurt knees have an insatiable desire for knowledge, and they're eager to tell their stories, hoping someone can provide a glimmer of insight. As I've made clear (I hope), I'm NOT a physical therapist or a doctor, just someone who did a lot of reading and experimenting who saved a pair of bad knees that doctors said would never get better. So I won't offer any advice, more like "things to think about and discuss with a medical professional." We'll see how it goes.

If You're Having Problems of Any Kind Buying/Reading "Saving My Knees," Read This

"Saving My Knees: How I Proved My Doctors Wrong and Beat Chronic Knee Pain" is now on Amazon.com as an electronic Kindle book. I'm still waiting for the product description to be added, but the book is ready to be ordered and downloaded.

Why is it only electronic? That answer's here.

How can you read it? Or buy it if you live abroad? That answer's here.

Now, what if, after following the instructions given on the link above, you still don't have a way to buy or read the book?

Welcome to the trouble-shooting post. I'll fix problems here, best I can. Explain your issue in the comment section below and I promise to periodically update this post with possible solutions.

How Can You Read "Saving My Knees," an Electronic-Only Book, If You're Kindle-less?

Q: Argh ... I didn't find an Amazon Kindle under my Christmas tree this year, so how can I read your book "Saving My Knees"?

Another made-up question ... but I wanted to do three blog posts, addressing three important matters. One: Why is the book electronic only? Two: How can I read it then? Three: What if I still don't have any way to read it?

Today's installment: "How can I read it then?"

Amazon should be processing the book in the next 24 hours, at which point I'll add a link here to where the book can be found online. If you own a Kindle or Kindle DX, you can download "Saving My Knees" and you're off to the races ... you'll be virtual-paging through almost 55,000 words that will get you thinking about your knees in new ways and challenge some of your beliefs about how to heal.

But what if you don't have a Kindle? Here are some solutions, all of them absolutely free.

If you own an iPad, you can download "Kindle for iPad," which should enable you to read any of Amazon's electronic books on your iPad.

If you own an iPhone, you can download "Kindle for iPhone."

If you own a BlackBerry or Mac, or a device that uses either the Android or Windows Phone 7 operating systems, go here for your solution.

I saved the best for last, because most of us own ordinary ol' PCs and not any of this other fancy gadgetry. That's no problem at all, as "Kindle for PC" will set you up nicely to peruse e-books all day long.

I've been using Kindle for PC for a few weeks now (partly to preview "Saving My Knees," to see how it will look as an e-book). I usually refrain from being a software cheerleader, but Kindle for PC is very, very neat, even if, like my good friend Molly, you hate technology and belong to the Lead Pencil Club.

First, the feature set: If you've just finished the Evelyn Wood speedreading course, you can display the book in newspaper-like columns, to whiz through the content faster. If you like your book to fill the computer screen, that's an option. If you want to change font size, font display, or how many words are crammed onto a line, you can tweak any of that, easily. And it goes without saying that you can quickly jump anywhere you want to in the book.

Kindle for PC does other things too, but here's what I think is coolest: it opens up a whole new world of free books. Access to free, quality content always elevates a good piece of software to great. For example, old books in the public domain (whose copyright protection has expired) can be downloaded from Amazon ... at no cost (I'm a huge Lewis Carroll fan so my first selection was "Alice in Wonderland"). Also there are some modern books that cost absolutely nothing too, such as a rather good thriller I downloaded for kicks.

Okay, you may be thinking: I've got a device to read the book on. But I live abroad. What about payment? (You'll pay $9.99 at most for "Saving My Knees", depending on the size of Amazon's discount.)

As I understand, Amazon's U.S. e-books are available through the U.K. site (with the payment automatically converted to pounds). My guess is that Amazon will expand this option this year to other countries ... we'll see.

So what about the rest of you, who don't live in the U.S. or the U.K.?

I'll admit I haven't done a lot of research into this yet. But I did find a Web page that shows how to buy a Kindle book from Amazon.com without a U.S. billing address, by using a gift certificate purchased with an international credit card.

Note: I can't vouch for this method, as the site is not Amazon-sanctioned, but anyone who gives this option a try, share your experience in the comments section and I'll be sure to update this post.

So there you have it! If this still doesn't help you, the last of these three posts will throw the floor open to the truly hard-luck cases to describe their problems, and we'll figure out solutions.

I want this book to be distributed as widely as possible because I think the message is very important and this kind of inspiring, fact-based story isn't available anywhere (and, amazingly, I've yet to find the scientific studies that I cite in "Saving My Knees" in any other "heal your knees" books). My hobby is troubleshooting and thinking around corners (that was part of the secret to my success in recovering), so I'm sure we'll find a way for everyone who wants to read this book to have that opportunity.

Why Is "Saving My Knees" Available Only as an Electronic Book?

Q: I have followed your blog and read your comments about beating knee pain at sites including KneeGuru, and am curious about your story. I would like to read "Saving My Knees." But why is it available only as an electronic book? Why can't I buy a paperback version? Couldn't you find a publisher? If not, why not, if this book is really any good?

Okay, that's an invented question. But it's a good one. If I had knee pain and was about to lay down a ten spot for a book that exists only in bits and bytes, that I can't carry to the park on a warm, sunny afternoon, I'd sure as heck want to know the answer.

After all, you may be thinking, here's a guy who's well-educated (I attended Harvard, then New York University for a master's degree), who is a veteran journalist working for a leading global news organization, who undertook a closely observed and unprecedented experiment to save his knees, whose extensive research into knees and cartilage is reflected in a Select Bibliography that spans three single-spaced pages -- and he can't manage to sell a book about how he beat knee pain, in a world where there are tens of millions of knee pain sufferers?

Something doesn't make sense here. Something must be wrong with this book, right?

At this point, I'm going to turn the tables and engage you, the reader, for a moment. Because when I was hurting all the time, I very badly wanted to buy a smart, sensible book written by someone who conquered knee pain. I desperately sought hope. I wanted an inspiring story to lift my spirits. And I bet you've probably looked for the same thing.

Now here's my question: How many books fitting that description have you found on the shelves of your local bookstore? Go ahead. List all the titles.

I'll give you a minute. Okay, a few minutes ... still waiting ...

I'm guessing that your list looks about the same as mine would've, four years ago. Zero. No books. Nada. We don't really need another knee book written by a medical doctor (sometimes paired with a physical therapist), full of stiff writing and photos of exercises and rather dull anatomy lessons. We've got plenty of those. But we don't have any first-person accounts that speak more personally to a knee pain sufferer: I was there, I hurt all the time too, and I beat this thing, dammit, and here's my story. So there clearly is a profitable niche, just waiting to be filled.

Now brace yourself: This niche is not going to be filled. And now I'm going to tell you exactly why.

When I began approaching literary agents with my manuscript, very excited -- I had written and extensively rewritten "Saving My Knees" and even hired four perfect strangers, for a small sum of money, to review this manuscript and make suggestions, which led to further changes and improvements -- I soon slammed hard into a brick wall. It became clear to me no agent would agree to represent my book to publishers, and no publisher would ever agree to buy it.

Why? As an agent told me bluntly, I'm not a doctor. I'm not an authority about knees who possesses a medical degree. Of course there's a rich irony here. Had my supposedly qualified doctors written a book about me several years ago, the title would have been something like, "Why Richard Bedard's Knees Won't Heal: A Look at Why Knees Afflicted by Chronic Pain, That Don't Respond to Treatment, Never Get Better." And of course that book would have been dead wrong.

I find it curious that it's not considered valid for me to write this book, even though journalists have a long history of writing about things that they're not degreed experts in. Examples could fill up pages. What makes a book about one's bad knees different? My guess is publishers would identify two main things: (1) This is a health-related book, and a different standard applies. (2) This is my personal story of how I healed, so there may be a presumption that I'm offering advice, a la a doctor.

Now when you read my book (assuming you do), you'll find the advice I do give isn't all that radical. For instance, one of my four golden rules for bad knees is "lose weight." Simple. But while the doctor wags a finger in your face and says, "Lose weight and that will help your knees," I don't wag a finger in your face. I show you -- through my experience and studies I have read -- why you need to lose weight. You can wag your own finger in your face. :)

So my not being a doctor (or physical therapist) was a big obstacle to getting this book published. But I also realized that, even if I surmounted that obstacle, another one just as big awaited me.

Let me take a moment to show you what that was. I'll do so by presenting you with the following hypothetical, that takes us on a little historical journey:

It's two hundred years ago. You're a journalist. You have asthma. You go to a doctor, describe your asthma symptoms, and he recommends a controlled bleeding from your arm into a bowl (Google "bleeding bowl" to see what I mean) to correct your breathing difficulties. You think to yourself, "Okay, I'm not a doctor. I do know that doctors often prescribe this bleeding into a bowl thing. I'll submit to whatever he thinks is best because he's the expert."

But a week after the procedure, you still have asthma, just as severe. You return to the doctor. He tries another controlled bleed. You go home, find yourself still struggling with asthma, then begin to wonder, "Hmm, why are they bleeding me into a bowl? How does that really help cure my asthma?" So you do a lot of research. You run some experiments on yourself. And surprise: you find that bleeding people into a bowl doesn't seem to make much sense for treating asthma. You finally find a way to heal, sans bleeding therapy.

So you write a book, hoping to inspire other asthma sufferers who think there is no hope. You title it: "Saving My Bronchial Passages: How I Healed My Asthma and Why Bleeding People Into a Bowl Isn't Smart Medicine for Asthma Sufferers." You get your manuscript in tip-top shape, then go out to try to sell it to major publishing houses, and they ...

Shut their doors in your face.

The problem is, they would need your book to be reviewed by medical professionals. And the state-of-the-art thinking in the medical community is that bleeding people into a bowl is an appropriate treatment for asthma. And you -- just an ordinary journalist without a medical degree -- are challenging this well-entrenched medical wisdom. Forget about finding a publisher.

Two hundred years ago, that would have been the end of the story, and you would have died clutching your unpublished manuscript -- frustrated, then vindicated later by medical progress.

Today, the Internet has democratized access to information. Sure, there's a lot of bad info to wade through. But for an optimist about knowledge, and about the contagion-like property of good knowledge, as I am, it's clear that a smart book about healing knees just might take on a viral property and spread to help millions -- even if the publishing establishment rejects it.

I can be a bit of a renegade, you'll find in "Saving My Knees." But that's not really my nature. I started out as a perfect patient. I became a renegade only after doctors and physical therapists failed to help me heal. You'll see that much of the advice and information I was given -- that I had a condition called patellofemoral pain syndrome, that I should focus on strengthening my quads, that taking glucosamine would help my cartilage heal, that stretching the iliotibial band was important to get better, and so on -- was most likely wrong or useless.

Following the advice of doctors and physical therapists got me stuck in an endless rut where I never got better (and even got worse, following a physical therapist's advice!), where I was constantly frustrated and depressed. I didn't start healing until after doing a major rethink of everything. The major rethink didn't involve me staring at my navel and thinking big thoughts. I went to Knee School 101, Self-Directed Study. I pored over many clinical studies and medical textbooks -- and stumbled upon the writings of an incredible physical therapist, Doug Kelsey.

So that's my long-winded answer why you should trust a guy peddling an e-book. "Saving My Knees" is my story, certainly. I don't pretend that you need to do exactly what I did, to save your knees. But I think that I discovered a framework for healing -- and I'd be surprised if my observations don't help you in some way. Or at least give you hope -- and that may be just as important as anything for a knee pain sufferer.

Whoops! We're Out of Order!

Not in the Robert's Rules sense, but rather my latest post on whether to exercise through pain was put here by blogger.com, below my Christmas post, instead of above it.

That was probably because I started writing it up on Dec. 24, then abandoned the effort because of a bad head cold, and went with a short "Merry Christmas" theme instead.

Anyway, that explains why the last two entries look non-sequential, if anyone was wondering ...

Best Christmas Wishes to All

I had an ambitious blog post in the hopper along the lines of "How do you heal through pain-free motion when you're always in pain?" And I will get to it. Next week.

That's because -- alas -- my body has been steadily running downhill since about 10 p.m. last night, when a bit of viral grinchitude derailed my ambitious plans for Christmas Eve. Yes, I have a cold, with the raw throat and swollen sinuses as proof. My productivity, not surprisingly, has dropped off a cliff.

So I thought I'd weigh in briefly now with the obligatory holiday wishes and come back, hopefully recharged and restored, with some thoughts next weekend about exercising when you're in pain but don't want to exercise through pain. I began stitching together a post on that very topic this morning, but when you're not feeling good, it doesn't take long to run out of gas.

The good news is "Saving My Knees" is still on schedule. It looks like it'll be ready about January 8th as an electronic book through Amazon.com. I'll have a lot to say about that in a few weeks -- why only an e-book, how someone without a Kindle can read an e-book (short answer: there are lots and lots of ways).

But for now, I'm just eyeing the bed, after a call to the wife (who's still in China, a piece of my personal story I'll talk about some other time). It's been a good year for me and my knees. In about August 2010, I reached the point where not only was the knee pain that forced me to quit my job in April 2008 gone, but also I was back to racing my bike up hills with guys 20 years younger than me -- and most of the time, I was beating them.

Sweet.

So take care all. Keep your knees warm. Try to enjoy Christmas. If you're frustrated by your physical therapy, by your doctors, by yo-yo'ing back and forth and never really feeling like you're getting anywhere, there is a better way out there. That's what I discovered, the hard way, and why I wrote "Saving My Knees."

Blessings to you all.

How Is It Possible to Exercise Without Pain When Pain Is All You Know?

This question got me thinking a lot recently. Because when you have to move to heal your knees, but you want to avoid movement that causes pain, and you're always in pain ... well, how do you ever get out of the starting blocks?

While catching up recently on Doug Kelsey's great blog, I noticed he said this in November about pain, while counseling a hurt runner on how to return to his sport:

You have to go hunting for the point where symptoms show up, adjust, re-train, and go again. This is where people make mistakes. They fail to edge the training. They fear the pain. Pain is the guide; not the problem.

So if you're always in pain, is the answer to just exercise anyway and accept that there will be a certain amount of pain?

This is a very tricky question. Anyone who's been reading my blog/comments elsewhere (such as on KneeGuru) knows that two keys to saving my knees were: (1) Going slowly and being patient (2) Modifying activity when pain and even mild swelling occurred.

Here's what I did, and what worked for me, with regard to pain and exercise and daily activities:

First, I listened very carefully to my knees. Bad knees throw off many different kinds of unhappy signals. I worked hard to figure out which ones meant impending problems and which were just the background grumblings I had to live with. I reacted quickly to the pain/discomfort signals that I thought spelled trouble.

If I awoke and my knees felt subpar, for example, I might cut back my step count that day from 6,000 to say 3,000 or 4,000 (I'd also try hard to figure out what caused the backsliding in the first place, so as to change my future behavior.) But my adjustment was usually only for a few days at most. It doesn't do much good to be on an exercise "program" that consists of lurching about; consistency is good.

I learned, too, that pain signals can arrive a full TWO DAYS AFTER the offending activity (hyaline articular cartilage has no nerves -- that's a BIG issue when you're trying to heal). Once I had knee pain two days after moving a heavy fan. Puzzled, I studied my knee journal to see what else could have caused the pain. Nothing -- I'm 99 percent sure it was moving that fan.

My recovery was a matter of learning how to recognize pain signals (delayed and otherwise), backing off, strengthening my joints, then pushing the envelope again.

That's right: I was always pushing the envelope. I never thought to myself, "Okay, I'll just get to the point where my bad knees can walk two miles without too much of a problem, then that'll be good enough -- I'll just accept I have bad knees that can walk only two miles." I wanted to heal and make my knees strong again, so I could resume the intense cycling I loved. I had big goals.

This is what Kelsey is talking about with that nice phrase, "edge the training." You have to push yourself beyond what's safe and comfortable.

The preceding reflects my personal experience. I realize I had a certain luxury though: my knees weren't absolutely shot by the time I intervened and managed to rescue them. Other people aren't so lucky. They're at the point -- because of failed physical therapy, or too much progressive damage over the years, or the severity of their initial injury -- where they simply can't get free of the pain.

So that brings us back to the original question: how do you exercise if everything always hurts?

Here are some of my thoughts for those with fairly constant pain. Discuss these with a medical professional to see if he/she thinks they make sense for you, in your situation:

* Can you do short bursts of activity? There was a period of my recovery, when I was half-convinced my doctors were right and I'd never get better, when I just did "walkarounds." Every ten minutes, I'd walk for a minute. It was a strange and boring regimen (bring a book!). For example, I'd go to a small park and walk around for a minute, then sit on a bench for nine minutes, then slowly walk for a minute, then sit back down etc.

Are there any motion-based activities your knees like? Moving in a swimming pool? Cycling backwards on a stationary bike (it requires less force and takes pressure off the joints)? At one point -- when I thought maybe I needed to go back to square one with my poor joints -- I even contemplated buying a continuous passive motion machine, secondhand, and just using that to give my joints frequent motion without too much strain.

* If nothing works for you -- you're still always in pain! -- you could experiment. I became a world-class experimenter. In fact, this helped stave off the boredom from what is, in the best of circumstances, a very, very slow recovery. Dedicate a week to a program of movement -- keep it at the same level all week (obviously if your knees start sliding downhill, adjust).

You do need to be fairly scientific-minded when you experiment, I found (buy a pedometer to track your steps!). If you don't keep as many day-to-day variables as constant as you can, then it'll be hard to tell whether your program of walking 4,000 steps a day is causing the problems, or whether it was that ill-advised trip to the racetrack when you had to stand for two hours in the same spot. In my book, I talk about how I became a guinea pig of my own making.

Also, I discovered that, with recovery from a slow-healing injury, it's best to focus on trend lines, not individual data points. In other words, say you start exercising Monday. On Tuesday, you say, "Eh, I feel about the same." Wednesday, you say, "I feel just a little worse." Thursday, you say, "It's been three days, overall I feel a little bit worse, I'm going to try something different."

The problem is, you may not have given your new regimen enough time. Try it for a couple of weeks. If, at that point, you say, "I'm definitely worse and going downhill," then maybe you are going in the wrong direction. But if you say, "I feel about the same," then you're probably winning. Why? Because you feel about the same but you're moving a lot more. That extra movement is laying the base for even more movement, and that's the path to healing bad knees.

* If experimenting isn't your cup of tea, or you don't feel you're getting anywhere, I'd look for a good physical therapist who is equipped to measure, scientifically, the strength of your bad joints and help you fashion a program to improve them. This involves more than someone examining your knees and saying, "Okay, do 10 of these and 20 of these" and so on. You need a physical therapist who can tailor a specific, joint-friendly exercise program for you.

Okay, that's a long-enough entry. I'm sure I'll return to this subject later. Now back to the book -- I'm coming down the home stretch and think we'll be ready to launch next weekend. Exciting moment! More information to come later and I will reveal why it's coming out only as an e-book. Stay tuned! :)